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Background  Peer Assessment (PA) in health professions education encourages students to develop a critical attitude towards their own and their peers’ performance. We designed a PA task to assess students’ clinical skills (including reasoning, communication, physical examination and treatment skills) in a role-play that simulated physical therapy (PT) practice. Students alternately performed in the role of PT, assessor, and patient. Oral face-to-face feedback was provided as well as written feedback and scores.  This study aims to explore the impact of PA on the improvement of clinical performance of undergraduate PT students.    Methods  The PA task was analyzed and decomposed into task elements. A qualitative approach was used to explore students’ perceptions of the task and the task elements. Semi-structured interviews with second year students were conducted to explore the perceived impact of these task elements on performance improvement. Students were asked to select the elements perceived valuable, to rank them from highest to lowest learning value, and to motivate their choices. Interviews were transcribed verbatim and analyzed, using a phenomenographical approach and following template analysis guidelines. A quantitative approach was used to describe the ranking results.    Results  Quantitative analyses showed that the perceived impact on learning varied widely. Performing the clinical task in the PT role, was assigned to the first place (1), followed by receiving expert feedback (2), and observing peer performance (3). Receiving peer feedback was not perceived the most powerful task element.  Qualitative analyses resulted in three emerging themes: pre-performance, true-performance, and post-performance triggers for improvement. Each theme contained three categories: learning activities, outcomes, and conditions for learning.  Intended learning activities were reported, such as transferring prior learning to a new application context and unintended learning activities, such as modelling a peer’s performance. Outcomes related to increased self-confidence, insight in performance standards and awareness of improvement areas. Conditions for learning referred to the quality of peer feedback.    Conclusions  PA may be a powerful tool to improve clinical performance, although peer feedback is not perceived the most powerful element. Peer assessors in undergraduate PT education use idiosyncratic strategies to assess their peers’ performance.

Why peer assessment helps to improve clinical performance in undergraduate physical therapy education: a mixed methods design